Caregiving is the central feature of nursing homes and quality care to residents can be improved by addressing shortage of RNs, LVN/LPNs, and NAs. In 2000, Harrington, Kovner, Mezey et al. posited that stakeholders and experts reached a consensus that the level of nurse staffing was too low and impaired with the provision of quality care in some facilities. Fast forward to over a decade and a half later, the healthcare sector faces the same challenge. Harrington, Schnelle, McGregor et al. (2016) observed of the imperative need to raise minimum nursing staffing levels. Many nursing homes in the US are inadequately understaffed with nurses, posing serious quality issues. This paper examines critical aspects of nursing staffing and its association to patient safety and quality care through review of components of the bill introduced to Congress seeking to amend nurse-to-patient staffing ratios in nursing homes.
Policy Problem Description
Nurse shortage continues to ail the healthcare sector and its causes are multifaceted: declining pipeline of new nursing graduates as thousands of prospective students continue to be turned way due to faculty shortage, rapid population growth in some states, increased access through Patient Protection and Affordable Care Act, and the need for intensive services brought by baby boom. Other contributors to nursing shortage are aging population and workforce, hospital acuity from reduced length of stay facilitated by technological efficiency, and workload and environment such as mandatory overtime policies in circumstances where patient number rises unexpectedly. Low staffing of nurses implies that nurses work for long hours under stressful conditions and the outcomes are fatigue, injury, and job dissatisfaction that impairs quality of care. Patients face the risk of preventable complications, medication errors, emergency room overcrowding, and increase in mortality rates. These and other factors were established by Congress as posited in section 1 of the 2017 Act.
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Social and Economic Factors
Registered nurses represent the largest group of healthcare professionals in the US. However, vacancies for the same have continued to rise with recent figures from nursing solutions quoting it to be 7.2%. The US Bureau of Labor Statistics in its 2017 job outlook report projected employment of RNs to grow by 16% by 2024, surpassing average allocations for all other sectors. While the US grapples with low nursing staffing, some hospitals explore ways of reducing their nurses as a means of enhancing profitability owing to the prevailing economic uncertainty (Everhart, Neff, Al-Amin et al. , 2013). According to Reiter, Harless, Pink et al. , (2012), 80% of direct nursing costs comprise of salaries and benefits, and amount approximately to 44% of the total cost of inpatient care. Therefore, some stakeholders, especially hospital, have expressed concerns about the controversial nature of nursing staffing regulations.
Nevertheless, social and economic effects have been demonstrated, though Shamian and Ellen (2016) argued that they are poorly understood via existing practice, scientific, policy, and professional frameworks. Nursing advances the important human values of compassion, advocacy, respect, caring, and social justice that form its core and cannot be assigned numerical financial value. Constant interaction with nurses has been established to reduce the likelihood of patients dying by 7%, incidences of family violence (Eckenrode, Ganzel, & Henderson, 2000) and improve health outcomes in women with post-partum depression (Tamaki, 2008). Shamian and Ellen (2016) highlighted economic benefits of nursing staffing, which are measured in terms of productivity, reduction in medical costs, reduction in length of stay, and reduction in readmissions.
According to Shamian and Ellen (2016), and increase in RNs would increase productivity due to decrease in length of stay by approximately $231 million. Dall, Chen, Seifert et al. (2009) established that employing an extra RN generated #60,000 in medical costs yearly. Similarly, Wang, Vernon-Smiley, Gapinski et al. (2014) established that employing RNs to provide services in school based health programs prevented the loss of $20 million in medical costs, and $28 million in parents productivity loss and $129 million in teachers productivity loss. Every dollar invested in the program with RN generated $2.20 totaling to $98 million in benefits to the society. data on economic and social benefits of high nursing staffing shows the potential to avoid costly patient errors, overcome overcrowding due to restricted bed capacity and length of stay, and address high turnover rates estimated at $70,000 and retention rates approximated to be $3.6 million, improve reimbursement, and initiate changes in inpatient population. A report by the American Nurses Association published in 2015 posited that better staffing reduces patient falls that cost approximately $17,000 per hospitalization, pressure also that cost $37,800 per stay, and other infections.
Ethical Factors
Poor nursing staffing negatively affects the quality of care and increases impacts on the bottom line. Ulrich, Taylor, Soeken et al. (2010) identified staffing patterns, practices of nursing professionals, and high levels of stress to be among the ethical issues related to the policy under discussion. It is evident that the issues are an extension of the effects of low nursing staffing highlighted earlier. The implication of low nursing staffing is that overwhelmed nurses are unable to operate by the ethics code of conduct: do no harm, act in the best interest of the patient, be masters of their craft, and share information and successful techniques. Low nurse-to-patient ratios expose nurses to unintended unethical practices leading to medication errors, wrong diagnoses, and increase in patient mortality. These factors have the potential to attract litigation from the affected party, which not only places the professional conduct on the nurse in question, but also affects the reputation of the health facility in which the incident took place.
Issue Statement
Nursing staffing continues to be a persistent problem in the US healthcare sector and its and evidence of the positive outcomes of high nursing staffing levels and negative effects of low nursing staffing levels have seen intensified calls for staffing patterns that are safe for the patient, safe for the nurses, and safe for the institution.
Stakeholder Analysis
The federal government represents the most influential stakeholder in the bill. In 2014, the US Department of Health and Human Services published a report projecting a 33% increase in the number of RNs between 2012 and 2025, representing a climb from 2.8 million full time equivalents in 2012 to 3.8 million in 2025. It is important to point out that the federal government is responsible for the training of majority of these nurses. In addition, the federal government has the responsibility to oversee the constitution of different committees to facilitate implementation of staffing regulations and ensure compliance. The role of the federal government makes it the highest ranked stakeholder with significant power and resource for influencing enactment and implementation of the bill if passed.
Another stakeholder is the hospitals. The Federal Regulation (42CFR 482.23(b)) dictates that hospital certified to provide Medicare must have adequate number of LRNs, licensed practical (vocational) nurses, and other professionals needed to address all patient needs. However, the law is not specific about what number is adequate, which leaves deliberation role to the hospitals. The report by the Joint Commission on staffing standards posited that effectiveness is dependent on the number, competency, and skills mix. Hospitals have the mandate to ensure these attributes and have the nurse executive which develops policies, procedures, standards, and staffing plans. Therefore, the input of hospitals during enactment and implementation is immense. Given the benefits of high nursing staffing, hospitals are likely to support the bill and also rank high as stakeholders.
Nurses also represent a key stakeholder in the bill because they are the first beneficiaries. The American Nurses Association has reiterated the role of reduction in the workload in improving productivity of nurses and hence patient outcomes (Shamian & Ellen, (201). Though nurses may have no influence on the bill during the enactment phase, they form a crucial component of its implementation, which ranks them as medium level stakeholders.
However, private health facilities may not be in full support of the enactment and implementation of the bill as it infringes on their autonomy to make profit. Everhart, Neff, Al-Amin et al. (2013) noted that rather than increasing staffing levels, some hospitals were conducting streamlining of their nurses to compensate for harsh economic times. Implementing the bill is passed would threaten these institutions out of business, hence their unwillingness to support the bill, especially where the number of nurses required is concerned. This ranks them as the lowest stakeholders, hence they need to be reminded that quality care should be available to patients regardless of the state of the hospital, and choice should be left to the patient by ensuring the both public and private hospitals have high staffing levels.
Alternative Policy
H.R.2392: Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2017.
The bill seeks to address nursing staffing standards through amendment of the Public Health Service Act, thus requiring hospitals to conform to the Department of Health and Human Service Staffing recommendation. The bill also intends to make it mandatory for hospitals to keep records of nurse staffing for all units in a bid to facilitate effective auditing and identify ways of increasing the number of nurses in understaffed units. The objectives are informed by the findings of Congress that link nursing staffing with nurse performance and quality of care.
Evaluation of Bill
The bill is expected to ensure appropriate nurse-to-patient ratios in nursing homes settings thereby improving productivity of nurses and quality of care. Empirical evidence exists of the effectiveness of high nurse staffing and so does that of the negative impacts of low nurse staffing. However, different stakeholders have varied perceptions on the implementation of the bill, with hospitals bearing the brunt of the negative effects including costs of hiring new nurses to meet the recommended threshold.
The report by Congress corroborates findings by different nursing bodies that improving nursing staffing reduces the workload, which in turn improves their performance as they can allocate enough time to each patient. Health facilities would also invest to increase their bed capacity with high nurse staffing reducing incidence of overcrowding. More importantly, reduction in the workload would reduce stress levels among nurses and consequently incidences of medication errors, misdiagnosis, and mortality cases. However, as evidenced by the reluctance by some health institutions, especially private hospitals to implement the bill citing controversy in its lack of clarity about what number constitutes the right staffing level, it would be a challenge to overhaul existing frameworks, implying that implementation of the bill, if enacted, should be gradual.
Finally, it is important to understand that the bill seek to address the issues of inequality in access of healthcare services by ensuring quality care is available in all hospitals regardless of their state. While the number of nurses is projected to surpass the demand in the next one decade, challenges of ethnicity and gender remain. It is cannot be said with certainty how many male or female nurses are needed to address patients’ concerns about being handled by a nurse of opposite gender. In addition, ethnicity plays a significant role in advancing health disparity in the US, hence the need to ensure that RNs are drawn from all ethnic and racial groups including minorities to facilitate bridging of such gaps in access to healthcare services.
Results of Analysis
On the basis of the findings discussed herein, adoption of the bill is highly recommended. Patient care continues to be a significant burden to the taxpayers largely due to understaffing of nurses in healthcare settings. If the policy will solve the persistent problem of nursing staffing, it implies that reduction in length of stay, medication errors, mortality rate, and other avoidable issues, will save the government millions of dollars in medical costs. However, ethical issues relating to the policy have been raised. As the US continues to train nurses to fill the existing 7% vacancy, it has to employ short term solutions. One of them is the use of foreign nurses, which has attracted scrutiny, especially in relation to working conditions and environment to which they are unfamiliar, in addition to trust issues among patients. In addition, language barrier is common and impairs access where foreign nurses are involved.
The US has also been criticized of causing brain drain in the developing countries from which foreign nurses are imported. Compensation of foreign nurses, training of locally based ones, and processing of litigations related to labor and recruitment laws as a result of implementing the policy is likely to cost the government substantial financial resources. It is realistic to say that the paradigm shift needed to ensure integration of the policy into the healthcare sector would take time, implying that the benefits of the policy would be realized in the long-run.
As noted earlier, concerns have been raised by stakeholders, notably hospitals about the controversial nature of the policy. The bill is ambiguous on what is the appropriate nurse-to-patient ratio. Though federal level may be set by the respective bodies, the clause needs to be revised to match staffing levels with hospital capacity. In addition, every hospital should retain the autonomy to staff it units with the government only playing the role of the enforcer. Additional frameworks need to be developed to categorize hospitals based on the services they provide and recommend appropriate staffing ratios rather than generalizing the requirements.
Conclusion
Nursing staffing is a perennial issue in the US healthcare industry. Over the years, efforts have been made to address nurse shortages in hospitals without success. The bill discussed herein represents a federal government initiative to stamp its authority in solving the problem. Contents of the bill were inspired by evidence showing existence of a positive correlation between nursing staffing, quality of care, and patient outcomes. Implementation of the bill would facilitate realization of social and economic gains, but would also attract ethical concerns in the recruitment of foreign nurses. However, it is evident that benefits of the implementing the policy outweigh its demerits as it would improve quality of care while saving the government millions of dollars in medical costs.
Talking Points
Hospitals in the US have been understaffed with nurses for a long time, yet they are the most critical component of the healthcare sector
There is a consensus among stakeholders to increase nurse-to-patient ratio in nursing home
High nurse staffing has been established to address problems caused by low nurse staffing including medication errors, length of stay, mortality rates, and overall quality of care
The nursing vacancy in the US is higher than any other labor sector at 7%
Low nursing staffing has been linked to poor social and economic outputs
High nurse staffing is associated to reduction in medical costs due to improved productivity, quality of care and patient outcomes
The bill advances equality in access of healthcare and would make the sector competitive
Stakeholders face social, economic, and ethical challenges in implementing the bill if passed as the current number of RNs is insufficient to meet market demand
Hospitals face challenges in overhauling the existing staffing frameworks due to economic implications
References
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